Customer Reviews

Forgive and Remember: Managing Medical Failure

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As a medical student at the University of Chicago, Forgive and Remember helped shape my view of what good, caring physicians need to do when policing their own. I am currently on the quality assurance committees at three hospitals where I practice. I am buying several copies of Forgive and Remember for my committee colleagues who have not read this book.

The temptations of money over our patient's best interest, the medical malpractice environment, and the difficulties of practicing medicine in the era of managed care have made it diffuclt for well intentioned physicians to make a difference in the quality of care provided in our communities. I think this book will help me and my colleagues fufill the responsibilities the hospitals and our commununities have given us.

I truly believe all health care providers, attorneys involved with medical malpractice cases, and people interested in the delivery of healthcare need to read this book. It brings into perspective how all health care providers, from surgeons to orderlies, are human and make mistakes. It also shows how some mistakes are hard to forgive. As physicians we have to take this into account while assuring we always keep the interest of all patients, our own and those of other physicians, are well looked after.

I hope that in my local community all people will trust that their health care providers, despite the outcome of their care, did a good, competent job. Everyone alive, including physicians and our families, will someday become a patient.

In life it is important for all of us to learn from our mistakes.

This book is required reading at my ENT residency, for good reason. Bosk applies a somewhat technical (for me) sociological paradigm to a surgical residency, focusing on the relationships between faculty and residents. Again and again the issues that he so clearly elucidated come up throughout my residency. It is doubtfully of use to non-physicians, but I highly recommend it if you are beginning residency.

This book captures the essence of training an academic surgeon in America. As a surgical resident, I can attest to the accuracy and relevance of this work. A "must read" for trainees in Surgery or surgical sub-specialties.

I first read this in surgical residency (on the west coast at a place very much like Pacific Hospital) in the 1980's and found his thesis very insightful. It was the first time anyone talked systematically about medical errors. Residency training was changing even then, and must be very different now-I practice in a rural area far from the ivory towers-but despite being technically very innovative, surgery is a very conservative field. I like to believe the vigilance and the sense of personal responsibility to one's surgical patients remains as strong. My thinking about errors has evolved, but the gut feeling of personal responsibility for error instilled 20 years ago in residency, is as much a habit as the rituals of sterile technique. This book is a must for anyone wishing to understand medical errors and how to reduce them.

This book gives an astounding and unprecedented look into the social structure of the surgeon. After graduation from medical school, I spent 7 years in residency and another 13 years teaching surgery to residents. This book gives a sensitive and accurate description of the ethos of surgery and shows why being a surgeon is who someone "is" and not what someone "does".

While other reviewers focus on how Bosk examines medical ethics, as a researcher focusing on organizational behavior and quality, I find this a fascinating study of two broader topics. First, Bosk presents a sociological taxonomy of error that anticipates later work on human error (Reason's "Human Error," Perrow's "Normal Accidents"). Second, his discussion of the process of professional socialization is a must read for anyone doing work on management and the professions.

A must read for any Medicare central planner and anyone interested in healthcare reform.

In his classic study of medical education Forgive and Remember sociologist Charles Bosk points out that a misunderstanding about how physicians make the distinction between what is a reasonable treatment option that is later proven wrong and one that is an indefensible medical error, leads to a misunderstanding about how the medical profession can or cannot be controlled. The concept of a medical error is an indeterminate category, similar to what is beautiful or merciful (p.24). This indeterminateness is caused by the nature of medical knowledge itself which is constituted by two modes, scientific knowledge (or "general knowledge" in Hayek's terminology) and clinical expertise (or "local knowledge" in Hayek's terminology). Bosk points out that "arguments based on clinical expertise override those based on scientific evidence" (p.85). Local knowledge trumps general knowledge.

The apprenticeship that is a residency program for medical students in which an experienced attending physician conveys to the inexperienced resident when to follow scientific knowledge and when to follow clinical experience constitutes the most critical element of that education. Residents are expected to study and know the general rules. Attending physicians are expected to teach residents to recognize the exceptions to those general rules. That clinical acumen or clinical eye characteristic of an experienced attending physician, his clinical expertise, "is a charismatic possession, a gift of grace; its exact nature is a mystery" (p.92). Medical education has evolved over hundreds of years and is structured today partially as a way for medical residents to appreciate that mystery.

The assumption by Medicare and all medical central planners that the healthcare system can be made more efficient through centralized decision making far from the bedside clashes with how clinicians grapple with medical errors, understand their cause and implement remedies, a process that is "an extreme example of local knowledge" (Bosk's own terminology in p. xxiii). Bosk concludes that medical "errors are not events that can be counted. Their existence needs to be debated; the discourse over precisely what is and is not an error is necessary to the formation of a sense of professional responsibility."

If Medicare wants to have local patients, physicians and hospitals adapt quickly to the rapid pace of change happening at the local level in order to reduce costs, it would seem that the best and indeed only way to make that happen is to let the local people who are most familiar with those local conditions, local resources and local changes to make those adaptations. Centralizing that process only slows down adaptation at the local level, reduces coordination and increases misallocation of capital, supplies, and labor.

Only the free market and its price system and not central planning can solve this problem.